HIV associated nephropathy medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Ali Poyan Mehr, M.D. [2];Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD[3]Krzysztof Wierzbicki M.D. [4]
Overview
The treatment of HIV associated nephropathy (HIVAN) includes: combined antiretroviral therapy (cART), renin–angiotensin–aldosterone system (RAAS) blockade, corticosteroids and renal replacement with dialysis.[1]
Medical Therapy
Combined Antiretroviral Therapy (cART)
- Treatment with ART is recommended in all HIV-positive patients regardless of their CD4 count.[1]
- In a retrospective cohort study, patients with HIV associated nephropathy (HIVAN) with cART had a better renal survival compared to patients with no treatment.[2]
- In a cohort study, treatment with cART was associated with reduction in the incidence of HIVAN.[3]
Renin–angiotensin–aldosterone system (RAAS) blockade
- In a study, renal survival was increased in patients treated with captopril compared to non treated controls.[4]
- In another study, longer renal survival was reported in patients treated with fosinopril compared to untreated patients.[5]
- Treatment with ACE inhibitor/ARBs in HIV-positive patients is recommended when there is:[6]
- Confirmed or suspected HIVAN
- Significant albuminuria (>30 mg/day in diabetic patients and >300 mg/ day in non-diabetic patients)
- ACE inhibitors/ARBs have protective effects in patients with chronic renal disease (CKD) by decreasing proteinuria and the deterioration rate of renal function.[7]
Corticosteroids
- On renal biopsy of patients with HIVAN there is significant tubulointerstitial inflammation, which has been shown to decrease after steroid treatment.[1]
- In a retrospective cohort study, an association was reported between treatment with corticosteroids and the preservation of renal function in HIVAN patients.[8]
- Another retrospective study, reported that corticosteroids delay the progression of HIVAN to renal insufficiency.[9]
Renal replacement with dialysis
- All patients with HIVAN that have progressed to end stage renal disease (ESRD) should go through renal replacement with dialysis.[10]
- The rates of HIVAN progressing to ESRD increased between 1989 to 2006, but has declined since then to 2011.[11]
- There is no need to isolate HIV positive patients in the dialysis center unlike in infection with hepatitis B.[10]
- Predictors of poor survival for patients with HIVAN and on dialysis are:[12]
References
- ↑ 1.0 1.1 1.2 Palau L, Menez S, Rodriguez-Sanchez J, Novick T, Delsante M, McMahon BA; et al. (2018). "HIV-associated nephropathy: links, risks and management". HIV AIDS (Auckl). 10: 73–81. doi:10.2147/HIV.S141978. PMC 5975615. PMID 29872351.
- ↑ Atta MG, Gallant JE, Rahman MH, Nagajothi N, Racusen LC, Scheel PJ; et al. (2006). "Antiretroviral therapy in the treatment of HIV-associated nephropathy". Nephrol Dial Transplant. 21 (10): 2809–13. doi:10.1093/ndt/gfl337. PMID 16864598.
- ↑ Lucas GM, Eustace JA, Sozio S, Mentari EK, Appiah KA, Moore RD (2004). "Highly active antiretroviral therapy and the incidence of HIV-1-associated nephropathy: a 12-year cohort study". AIDS. 18 (3): 541–6. doi:10.1097/00002030-200402200-00022. PMID 15090808.
- ↑ Kimmel PL, Mishkin GJ, Umana WO (1996). "Captopril and renal survival in patients with human immunodeficiency virus nephropathy". Am J Kidney Dis. 28 (2): 202–8. doi:10.1016/s0272-6386(96)90302-9. PMID 8768914.
- ↑ Wei A, Burns GC, Williams BA, Mohammed NB, Visintainer P, Sivak SL (2003). "Long-term renal survival in HIV-associated nephropathy with angiotensin-converting enzyme inhibition". Kidney Int. 64 (4): 1462–71. doi:10.1046/j.1523-1755.2003.00230.x. PMID 12969167.
- ↑ Lucas GM, Ross MJ, Stock PG, Shlipak MG, Wyatt CM, Gupta SK; et al. (2014). "Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America". Clin Infect Dis. 59 (9): e96–138. doi:10.1093/cid/ciu617. PMC 4271038. PMID 25234519.
- ↑ Sarafidis PA, Khosla N, Bakris GL (2007). "Antihypertensive therapy in the presence of proteinuria". Am J Kidney Dis. 49 (1): 12–26. doi:10.1053/j.ajkd.2006.10.014. PMID 17185142.
- ↑ Eustace JA, Nuermberger E, Choi M, Scheel PJ, Moore R, Briggs WA (2000). "Cohort study of the treatment of severe HIV-associated nephropathy with corticosteroids". Kidney Int. 58 (3): 1253–60. doi:10.1046/j.1523-1755.2000.00280.x. PMID 10972688.
- ↑ Laradi A, Mallet A, Beaufils H, Allouache M, Martinez F (1998). "HIV-associated nephropathy: outcome and prognosis factors. Groupe d' Etudes Néphrologiques d'Ile de France". J Am Soc Nephrol. 9 (12): 2327–35. PMID 9848787.
- ↑ 10.0 10.1 Menez S, Hanouneh M, McMahon BA, Fine DM, Atta MG (2018). "Pharmacotherapy and treatment options for HIV-associated nephropathy". Expert Opin Pharmacother. 19 (1): 39–48. doi:10.1080/14656566.2017.1416099. PMC 6381591. PMID 29224373.
- ↑ Razzak Chaudhary S, Workeneh BT, Montez-Rath ME, Zolopa AR, Klotman PE, Winkelmayer WC (2015). "Trends in the outcomes of end-stage renal disease secondary to human immunodeficiency virus-associated nephropathy". Nephrol Dial Transplant. 30 (10): 1734–40. doi:10.1093/ndt/gfv207. PMC 4829059. PMID 26175146.
- ↑ Atta MG, Fine DM, Kirk GD, Mehta SH, Moore RD, Lucas GM (2007). "Survival during renal replacement therapy among African Americans infected with HIV type 1 in urban Baltimore, Maryland". Clin Infect Dis. 45 (12): 1625–32. doi:10.1086/523728. PMC 4096866. PMID 18190325.